PERSONAL INFORMATION CLIENT CONSENT FORM
As part of my application for insurance, I hereby consent to the brokerage firm
“Advanced Insurance Brokers Inc.” collecting, using and disclosing personal information
required for purposes of considering my application for new or renewal property/casualty
and/or automobile and/or other insurance coverage.
“Advanced Insurance Brokers Inc” is authorized to collect, use, and disclose personal
information to third parties, as required, including insurance companies. “Advanced
Insurance Brokers Inc” may also be required or permitted to disclose such personal
information pursuant to the relevant privacy laws or other laws.
If I wish to review personal information pertaining to my application or policy maintained
by “Advanced Insurance Brokers Inc”, obtain copies of the Broker’s privacy policies or
standards, or make other enquiries or express concerns, I understand that I may do so
by contacting “Advanced Insurance Brokers Inc”’ privacy officer.
I agree that all the personal information provided to “Advanced Insurance Brokers Inc”
Will be complete and accurate.